More anti-THR junk science from UCSF, the new Karolinska

As I alluded to yesterday, there is another bit of anti-ecig junk science out today. Once again, it is from the Glantz shop at UCSF. Glantz did not put his name on this paper (presumably to create the illusion among the naive that this is not all part of a single organized disinformation campaign), but that hardly matters.

The little study (published as a “research letter”) followed a small group of smokers for one year, and compared quit rates for those who had recently tried an e-cigarette at the baseline survey and those who had not. They found that those in the former group had a slightly lower abstinence from smoking at followup. Clive Bates does a good job of pointing out how this thin result led to overblown conclusions, and then UCSF created a misleading press release, and this tricked the press into reporting out-and-out falsehoods. Do read Clive’s post for more — there is no reason for me to repeat it here. (If the NYT picks up the story, I might respond to that, but I am not inclined to spend any effort responding to random stories from unsophisticated news sources.)

It should be noted that unlike Glantz’s last paper, in which the conclusions did not follow at all from the study results, in this case the results do lean slightly(!) in the direction of their claims. That is, an honest reader, whatever he believed about the effectiveness of e-cigarettes for smoking cessation before seeing this result, should be moved slightly in the direction of believing that they are less effective, assuming he believes the researchers are presenting their research honestly.

It is important to attend to those italicized words. This group has such a long and consistent record of misrepresenting their studies, that a sophisticated reader will not put any stock in their claims without seeing a review of the instrument and data by an honest scientist. But even ignoring that, the information content of the result is so close to nil that it should not have much effect on people’s beliefs. Clive quotes the ACS’s Thomas J Glynn about the most obvious weaknesses with the study: small sample size and paltry information about e-cigarette use (in particular they did not try to distinguish between “tried one puff on an e-cigarette as a lark” or “not trying to quit and just use e-cigarettes in one particular non-smoking venue” from “actively trying to switch to e-cigarettes”, or from everything in between).

The more fundamental weakness is one that you are not going to hear from anyone in tobacco control, because it requires acknowledging that tobacco users are different kinds of people acting on different preferences, not biological agents with a condition that needs to be cured. Brad Rodu and I will soon release a paper that shows how this view is harmful to smoking cessation efforts. One minor point from that line of research: Confounding matters. [Confounding is the challenge that exists when the exposed and unexposed groups have systematically different outcomes for reasons that are not caused by the exposure.] This is at the core of any half-decent Epidemiology 101 course, but apparently they do not have one of those at UCSF. If smokers who are more likely to not smoke at a given date in the future (say, because they do not actually smoke all the time, or because they have decided to just stop unaided) are less likely to try e-cigarettes (for obvious reasons) then that will give you the correlation that was reported. This is why real social scientists always try to deal with confounding (not always very successfully, of course). Tobacco controllers, who believe that tobacco users are just dumb automata, and not people, do not even realize they are doing social science.

Clive also takes a swipe at a tobacco control crank who was foolish enough to enter into public debate on a previous post by Clive. That individual expressed glee about the upcoming publication of this study (which was circulated to tobacco control people in advance, so that they were all ready to use it for propaganda before the scientists had a chance to reply). Yes, glee is the attitude of tobacco controllers about a study that they (mis)interpret as showing that a stop-smoking tool does not work — they are such a compassionate bunch.

But what struck me most about Clive’s post was the observation:

Professor Stanton Glantz’ group … is rapidly becoming a slurry gusher of black propaganda, media-political spin and unethical practice. The release follows an established track….

That certainly seems to be the case. And that is hauntingly familiar to me, and probably to the handful of others like Brad and Clive who have been working on THR for more than a decade. Throughout much of the 2000s, one group of propagandists-cum-researchers at Sweden’s Karolinska Instetutet, took advantage of that university’s reputation as a medical school to spew out a series of biased and dishonest “studies” that claimed to show that smokeless tobacco (snus) caused a variety of diseases. Brad, I, and my colleagues at TobaccoHarmReduction.org, made a concerted effort to push back against this. (For those who want some background, here is some from all of us 1, from me and my colleagues 12345, and from Brad 1234.)

Despite it appearing long after smokeless tobacco had been demonstrated to be a very low-risk alternative to smoking — which would still be true even if some tiny risk were actually found — this junk science was used as political cover for those who wanted to restrict and otherwise attack THR, like those who wanted to maintain the ban on snus in the EU. This collection of lies continued through 2011 when it stopped abruptly. We would like to think that our efforts (including both extensive writing and an actual lawsuit) had something to do with that.

The comparison of Glantz et al. to the Karolinska group is a bit unfair to the latter. The Karolinska group was quite sophisticated, hiding their deception in statistical modeling choices that were only noticed by dedicated and sophisticated readers. Indeed, the aforementioned lawsuit was not an attempt at censorship, but a demand to see their data (which they were required to share under Swedish law, but never did) so we could demonstrate how the results would change if the data were analyzed honestly, rather than using their sneaky tricks. Moreover, there is every indication that some in that group did not believe that what they were doing was dishonest or bad science; manipulating modeling choices to intentionally fish for biased results is sufficiently common in epidemiology that they perhaps genuinely believed that it was not dishonest (kind of like the classic, “I am not doing anything wrong, everyone cheats on their resume/girlfriend/taxes!”).

This contrasts sharply with UCSF. It is difficult to imagine that they do not know they are lying. Their deception is not buried in complicated statistics that they could, perhaps, convince themselves to believe are not dishonest. Their lies are so obvious that every honest casual observer who reads their papers can spot them. Contrast the barrage with (usually accurate) criticisms of their claims, as opposed to only a dozen of us who were pointing out the lies from Karolinska.

This offers some reason for optimism. Karolinska went quiet in 2011, but it took almost a decade to make it happen. Their sophisticated deception was enough to fool honest scientists and could be used unhesitatingly by propagandists. By contrast, Glantz and his group are obviously clowns, and serious people (like, say, the FDA) are not going to buy into their silliness. Anyone who touts their claims immediately destroys his credibility. Even public health groups who do not exactly have a reputation for honesty about THR are balking — witness the ACS responses to both recent papers (though obviously such honesty and seriousness is not universal; e.g., the Robert Wood Johnson Foundation). Because the lies from UCSF are so blatant, there is already a concerted effort to shut them down, and it should not take a decade.

Unfortunately, even though the honest regulators are never going to buy this dreck, local city councils, often populated by people who barely passed high-school biology class, will believe it and naively implement restrictions on e-cigarettes. And millions of potential switchers will see the disinformation in the news and it will cause them to keep smoking. Thus, harm is being done — people are being killed — by UCSF’s lies every day.

By the time the Karolinska liars shut down, they were a voice in the wilderness. Pretty much no one else was still trying to make scientific claims that smokeless tobacco is measurably harmful. No serious observer will still question that e-cigarettes help many smokers quit in the year 2020 (roughly what 2011 was in the history of smokeless-tobacco-based THR). But let’s hope that the liars at UCSF are not allowed to continue to voice their lies until then.

8 responses to “More anti-THR junk science from UCSF, the new Karolinska”

Dear Mr Phillips, fun and wonderfully lucid as usual.
I have a small issue though with the last paragraph. Blanket ban on all smokeless is already a fact in more than 12 Indian states. On the drawing board in Bangladesh, Malaysia, Kazakhstan, Belarus and the Russian Federation (now including the Crimean peninsula, go figure). All as a result of the Karolinska reporting. Immediately picked up and used extensively by the Swedish Agency for Public Health and as late as december 19th 2012 cited in a live press conference with the new Health Commissioner for the European Union Mr. Tonio Borg

If 25% of the users of now banned smokeless in india (only) switch to cigarettes instead the net effect will be +211,000 dead per year. This is including the saving of (their math not mine) 60,000 dead per year from 155 million users of smokeless.

A very good point and good question. Before I respond, a clarification about India and Bangladesh (and I am guessing Malaysia and perhaps Kazakhstan): The products used there that the ANTZ have tried to call smokeless tobacco are not smokeless tobacco. Tobacco is sometimes one of the ingredients, but not the primary one, and not the one causing the harm. And they do seem to be harmful — up there with smoking — and thus switching to smoking might not matter much, but switching to snus, if it were available, would be a huge harm reduction benefit. The anti-snus disinformation is hurting them because it is discoruaging them from investigating it as an alternative. Search “gutka” in this blog click the “ST variants” tag for more.

Ok, back to your point: Yes, the continuation of the ban in the EU, and its expansion into states that want to join the EU (crazy, wanting that) as well as Russia (even crazier wanting to join Russia — go figure, indeed) can probably be traced substantially to the Karolinska lies. I agree that just because they stopped lying does not mean the downstream damage stopped. That is a good point. I am not really sure how to stop that from happening, other than grassroots education (i.e., one black market consumer at a time).

The good news is that because of the enthusiasm and networking of the e-cigarette community, lies like that are unlikely to keep fooling people 20 years after it became clear the products are low risk. That might not stop neo-feudal dictators (like the entire government of Russia, the health ministry in India, the nanny staters in Australia) from banning them, but it will keep educated consumers from being tricked.

Thank you very much for kind and timely reply Mr Phillips, don’t you sleep?

I am physically smack in the middle of all of this (Turkey – Northern Cyprus) and I see how only days after (European – US) legislation or policy’s on E-cig and/or Snus make in to the news – news emerge from anywhere around here on the Asian continent or in Africa with ambitious (turn-key-ready) legislative packages on blanket banning all smokeless and/or e-cig. All of them stating smoking kills so – and – so many people in their country therefore they are doing the only responsible thing: Ban everything BUT smoking.

One of the largest cigarette brands new strategic headquarters for sales has just been moved to Cairo. To me the message to be had from that is chrystal clear. I am a liberal and all for free market economy so I by definition have no problem with this. What I do have a problem with is that it seems some entities are really going out of their way to pre-fabricate a regulatory framework that will make it next to impossible for us producing and providing THR products to even have a fighting chance.

That is completely uncool and not fine with me at all! Free market is all about being the best in the marketplace – not the only one in the marketplace.

I argue that all of us should try and make a comprehensive product index putting cigarettes smoking at 1000. this will leave lots of room for refinement and emerging new products. In my example cigarettes would then be 1000, reasonable Indian smokeless 100, Swedish smokeless 10, and quite probably e-cig something like 2-5.

If enough of us can agree on one and back it up it would make for a fantastic graphic tool when discussing with governments and NGO’s. Also if we can make it and back it up – it would be up to the ANTZ to show numbers, studies, new studies etcetera showing that we are wrong.

Instead of the other way around as is the situation today.

BTW: This is of course not enough to base any epidemiological calculations on but India has 120 million smokers and 155 million smokeless users. India loudly proclaims it currently has 900,000 deaths from tobacco per year. All of us who fiddle with these numbers on a daily basis can easily calculate approximately how many deaths the 120 million smokers generate. The leftover dead would then have to be spread over the remaining 155 million. To me that comes to a harm reduction even with their versions of somewhere between 90%-95%.

I don’t sleep much :-).
I certainly does appear that rich white elitists who do not really care about health dictate the tobacco policies of poor countries. And unfortunately, people in rich countries are empowered to push back against them, but when they export their policies they are imposed on poor people who cannot do anything about it. I would not worry about cigarette companies being on the wrong side of this, though. Most of the internationals are solidly in the snus business and are moving into e-cigarettes or variations thereof. They have fought against the EU snus ban. They would rather their customers bought a product that was low risk, just like any other decent human being (i.e., not the ANTZ) would.

People make that graph all the time. And I always criticize it. 1000 for smoking and 10 for smokeless is probably about right — that is the conventional wisdom that goes back to my numbers from a decade ago. Indian dip products, however might be far worse than that 100, most notably because the diseases they cause strike at much younger ages. In a population that only lives to 50 on average, cigarettes actually do not cause much cancer. E-cigarettes, in their current form, are probably slightly higher risk than (real) smokeless tobacco.

Making sense of mortality claims is tricky. First, because they are just made-up numbers for the most part, which is kind of a fatal problem. But also because where they are really broken down and tied to some specific information (they are still nonsense, for the most part, but they are tied to something) is in rich long-lived populations, and thus probably do not translate well to India. That is, you might be tempted to do something like “India has twice as many smokers as the US, and claims almost exactly double the number of deaths as the US, and therefore they are attributing no deaths to the dip products (which they erroneously call tobacco)”. But that does not work, because the age distributions are radically different, Indians often do not live long enough to die from smoking, etc. And, of course, all the numbers are garbage in the first place.

Sorry, missed a point. Kazakh naswai is tobacco and wood ash and slaked lime. Some of the funkier stuff are tobacco, slaked lime, cloves, wood ash, betel quid, aracea nut and what have you. And then there are chews with only aracea nut or betel quid. And absolutely everything in between.

Therefore clearly what is necessary is a list of ok food grade ingredients (besides tobacco) and otherwise nothing else but tobacco (to qualify as a smokeless tobacco product and not something else that I am not going to bother with because it gets to complicated). and regular toxicology and microbial screens for ever and ever and ever to safeguard that producers stay up to par. Easy!

Thanks for the info on what the Kazakhs use. I did not know that. The lack of betel/areca might make it better. But the lime is quite possibly the main culprit. Wood ash is not exactly healthy either. Tobacco is clearly not the problem, as you say. Also, it is that tobacco with fewer microbes (i.e., is not fermenting) has less of some chemicals that are believed to be carcinogenic, but there is no real evidence if a difference in actual health effects.

Tobacco Harm Reduction (THR)

THR is the public health strategy of encouraging smokers to switch to low-risk alternatives like smokeless tobacco and e-cigarettes. It is the only proven method for reducing smoking below about a fifth of the population once it becomes established. (So why would anyone be anti-THR? See the "About" page.)

The continuing scourge of [smoking]-produced disease is unlikely to yield to today’s "evidence-based" interventions. (scare quotes added) Kenneth E Warner; see post if the implications are not obvious

If someone says the sky is green, you prove that it’s actually blue, and the next day he comes back once again insisting that the sky is green, and this happens repeatedly, you eventually have to acknowledge that mannerly debate about the color of the sky just isn’t enough; you have to go meta, and talk about the fact that this guy and his friends just aren’t in the business of honest discussion. Paul Krugman

He who is merciful to the cruel will become cruel to the merciful. Ancient Midrash